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Historical Review and Recent Advances
in Neonatal and Perinatal Medicine

Edited by George F. Smith, MD and Dharmapuri Vidyasagar, MD
Published by Mead Johnson Nutritional Division, 1980
Not Copyrighted By Publisher

Chapter 24

Maternity and Infant Care Services in Chicago
Retrospectus: Our Legacy, Our Challenge

Donald Dye, M. D., M. P. H. and Karen Tarpey, M.S. N., Dr. P. H.

 

BEGINNING LEGISLATION: 1876-1912

"Those who carry on great public schemes must be proof against the most fatiguing delays, the most mortifying disappointments, and the most shocking insults, and what is worst of all, the presumptive judgements of the ignorant."

-- Edmund Burke (1774)1

The Chicago Department of Health was established on July 3, 1876, during the administration of Mayor Monroe Heath, when an ordinance was passed abolishing the Board of Health which had been in existence since March 31, 1867. All of the powers and duties of the old Board of Health were, by said ordinance, vested in the Commissioner of Health as administrative head of the newly created department.2 However, the Board of Health was soon thereafter reconstituted and became the governing body of the Department of Health. Local governments in Illinois had been given rather broad powers to regulate public health. By the Cities and Villages Act, legislation authorized city councils to perform all acts and make regulations which were necessary or expedient for the promotion of health and supression of disease.[3] In addition to conferring this rather general power to promote the public health, the act contained numerous additional sections granting specific powers, such as the power to regulate the sale of meats, poultry, fish, butter, cheese, lard and other provisions; to declare and abate nuisances; to prohibit any offensive or unwholesome business or establishment within one mile of the city; to regulate cemeteries; to provide for the cleansing and purification of waters; and to erect, establish, and regulate hospitals, medical dispensaries, sanatoria and undertaking establishments.4

Under the powers thus granted, the city council established the Department of Health and passed numerous health ordinances. By ordinance, the Commissioner was charged with the enforcement of all laws of the state, ordinances of the city, and all rules and regulations of the Department of Health relating to the sanitary condition of the City. The Commisioner was appointed by the Mayor and salaried from corporate funds along with his designated staff or assistants and inspectors.[5] On July 24, 1876, Dr. Brock L. McVickar was appointed as the first Health Commissioner of the City. For administrative purposes, the Department of Health was divided into bureaus, one of which was the Bureau of Medical Inspection. The duties embraced under this bureau included the control of communicable diseases and child hygiene. And the division of child hygiene was charged with the responsibility for providing infant welfare services.

During this period of Chicago's history, the cause of obstetrical care of women was being championed by Dr. Joseph B. DeLee. Dr. DeLee founded the first lying-in hospital in the city, Chicago Lying-in Hospital, while he was an intern at Cook County Hospital. In February, 1895, he rented four rooms on the ground floor of a tenement house at Maxwell Street and Newberry Avenue for $12.00 a month. His objective was to provide free antenatal care and free home deliveries for Chicago's poor. DeLee initially paid his patients 25 cents each to let him deliver, their babies. Thirty-six years later he recalled[6] "the awful conditions of obstetric teaching and practice existent at that time," when obstetrics in Chicago was the virtual monopoly of midwives. He said:

"The best doctors refused to accept confinement cases and those who did were ignorant and careless. . . . The poor women had no care during childbirth except what a sympathetic neighbor or an ignorant, usually unclean, midwife could render . . . As a result many of the mothers died of childbed infection . . . and many of the babies were injured or became permanently blind. There was no lying-in hospital and the small . . . wards of the general hospital were frequently ravaged by puerperal fever epidemics . . . Obstetrics was held in low esteem."

Granted a charter in 1897, the Chicago Lying-in Hospital and Dispensary was founded[7]

"to provide proper medical care for poor women during confinement at their own homes, to establish and maintain a hospital for the care of such pregnant women as are without homes or need hospital care during confinement; to instruct students of medicine in the art of' midwifery and to train nurses in the care of women during confinement."

To these objectives DeLee added:

"deeper purpose ... to raise the standard of obstetric teaching and practice to a level equal to, indeed superior to, that of surgery and medicine, and to educate the public and the profession to the conviction that women at the gates of motherhood should have all the sympathy of which the human heart is capable."[6]

Espousing this purpose, Dr. Arthur R. Reynolds, Commissioner of Health, organized the first infant welfare work of the Chicago Health Department. In 1899 he recruited seventy-three volunteer physicians to serve families living in the densely populated districts of the city during the hot weather season. These doctors taught mothers how to feed, clothe and care for babies. They distributed the Department circular, "Hot Weather Care for Babies", which had been prepared by Dr. Frank Reilly, Assistant Commissioner of Health.[8]

Prior to the establishment of the Department of Health, the previously existing Board of Health had inaugurated milk inspection at the Stock Yards and, in 1870, introduced the first Milk Ordinance in Chicago 2 This ordinance made it unlawful to sell skim milk unless so labeled. The Department of Health continued to investigate the condition of the milk supply and, in 1902, played an active part in the establishment of the Milk Commission of the Children's Hospital Society of Chicago.

At the time there was much agitation in Chicago about the milk supply and the decision of the unions that milk should not be delivered to customers more than once a day. The people of the congested districts of the city were the special sufferers, having no ice in most cases nor proper facilities for storing the milk. The Health Department, searching for some method of relieving the situation, solicited the cooperation of the Children's Hospital Society. As a result, the Milk Commission of Chicago was established. It was composed of physicians, philanthropists, charity organizations, settlements and prominent citizens of Chicago.[9] For eight years the Milk Commission carried on the work of preparing and distributing modified and pasteurized milk for babies. The milk was distributed from the Commission's laboratory through various stations located at settlements, day nurseries and small parks. It was distributed at cost and arrangements for free distribution were made when required.

Many pathetic and ludicrous stories were reported to the Commission.[9] "At first much milk was returned because of the "yellow scum on top" which was thought to be medicine, many mothers never having seen cream." A great deal of persuasion was needed to get mothers to try this food for anyone but sick children. Mothers' meetings were held, pamphlets in nine languages were sent out, posters were placed in conspicuous places, doctors commanded and visiting nurses urged, and gradually, the demand for milk increased. It was the goal of the Commission to see that every child in Chicago who needed that milk obtained it.

In 1909, through the efforts of the Health Department and the Milk Commission, Chicago became the first city in the United States to adopt a milk pasteurization ordinance. According to C. E. A. Winslow, under the leadership of Health Commissioner William A. Evans, the Department of Health was becoming an educational machine of tremendous force and usefulness.[11] "Commissioner Evans told Presbyterian Ministers that while babies were dying, poisoned by dirty milk, the ideals of Christianity were not being realized and they knew he spoke the truth."

In 1908, Commissioner Evans enlisted approximately one hundred volunteer doctors to conduct, during the months of July and August, a house-to-house survey, visiting and instructing mothers about the care of their infants. And in 1909, the United Charities and the Visiting Nurse Association joined this effort. Using statistics of deaths, the Health Department staff mapped out the areas where infant mortality was the highest. Twenty nurses and fourteen doctors were employed in a campaign of home visiting at a cost of $10,000. The United Charities furnished nurses, tents, interpreters and social workers. Their work was made possible by the McCormick Memorial Fund. The Visiting Nurses supervised tents and assigned nurses to work in the districts.

The general plan of campaign followed was a house canvass by nurses in the most congested and unsanitary districts, where the greatest number of infant deaths had occurred during the previous years. Wherever small children were found, mothers were instructed about proper feeding and care. In the beginning, Health Department nurses were designated as case finding agents. The actual care of sick babies was assigned to the nurses of the Visiting Nurse Association, nurses of the Settlements in the districts, or nurses of United Charities who travelled out from stations of the Milk Commission.

This plan proved unsatisfactory, in that more sick babies were being found than could be served. This made it necessary for Health Department nurses to care for sick babies, in addition to acting as case finding agents. While the work performed during the eight years from 1902 to 1910 was of vast importance, a study of the infant mortality prevention problem showed the need for greater improvement.

The situation was told dramatically in the Health Department display at the Chicago Child Welfare Exhibit of 1912. A doll army of 3,800 figures was mounted to represent the children who died of preventable diseases in Chicago in 1911. In the same room another mechanical procession enforced the unnecessary slaughter of child life. In this display, every fourth doll in the line dropped into a grave to illustrate the fact that only three in every four infants "grow up."12

EARLY PROGRAM DEVELOPMENT: 1913-1932

The Department of Health entered the field of operating infant welfare stations in 1913 under Commissioner George B. Young. An appropriation made for this purpose by the City Council allowed the Division of Child Hygiene to operate infant welfare stations during four months of the year. In 1914, additional appropriations permitted three stations to operate all year round.[5]

The consensus of those who had experience and were endeavoring to reduce infant mortality, cited three active factors related to high infant mortality, namely, poverty, ignorance, and neglect. It was agreed that if these conditions could be removed, the infant mortality could be reduced to a great extent. Although public health officials had relatively little opportunity to improve the economic conditions of the community, much could be done to educate the people about the best way of expending income to obtain the most good for their families. [10]

Dr. John Dill Robertson, appointed Commissioner of Health in 1914 under the newly elected Mayor Henry Carter Harrison Jr., carried forth the infant welfare work of the Department along two lines: general field work and the operation of infant welfare stations. General field work consisted of home visiting by the Health Department's staff of school nurses during the months of July and August. The nurses located babies in the districts, distributed literature and instructed mothers about infant care. They endeavored to keep well babies well and advised mothers where to take sick babies for treatment. Infant welfare stations were operated during the entire year and conferences were conducted for the purpose of keeping well babies well. Mothers brought their babies to the conferences and the children were weighed and examined by the attending physician. A case record was kept on each baby registered. The nurses made home calls to see that the physician's directions were followed and assisted in carrying them out.

Each year from 1914 to 1918 a "Baby Week" was proclaimed by Mayor Harrison and subsequently by Mayor William Hale Thompson. During these weeks, intensive educational propaganda was conducted for purposes of stimulating public interest in the welfare of infants. All of the organizations interested in the welfare of babies, such as the Board of Education, United Charities, Infant Welfare Society and Social Settlements joined with the Department of Health. Newspapers, the clergy, motion picture theatre operators and various business organizations cooperated to make this movement a success.

In 1916, Commissioner Robertson directed the division to specialize on a sanitary survey in connection with infant welfare work, and in 1917 this survey was continued. The survey was a cross sectional study of the homes visited by the field nurses. The survey report form listed eight environmental factors (sanitary conditions) and the criteria for judging each factor. A scale of weights was assigned to each factor and numeric scores were tabulated for each report. This was the first major study of risk factors associated with infant mortality and morbidity. The quantification of health related factors by checklist and weighting system permitted a simple and informative analysis and report.

In 1918, the Department of Health extended the "Baby Week" in Chicago to cover the entire year. This cooperative effort was in keeping with the program of the Children's Bureau of the Federal Government and the Women's Committee of the Council of National Defense, making the second year one of vigorous activity on behalf of children. The year was designated as a "Children's Year" and plans were made to save 100,000 babies during the year. A special bulletin was published and distributed by the Department titled, "Danger Days for Baby" in which detailed directions for the summer care of infants were given.

At the close of 1918, recommendations of the Commissioner for the betterment of the Division of Child Hygiene included expansion of existing facilities and initiation of prenatal care:[8]

"The division, instead of having four infant stations should be operating 50, with an adequate budget for maintenance. No intensive prenatal work is being done, yet the need for this is urgent. The field is large and returns from cities where this work is being done show results that are convincing."

Other major contributions in the development of maternal and infant services, closely related to the work of the Department of Health in the early years of this century and in subsequent years, were made by Dr. Issac Abt, Dr. Julius Hess and nurse, Evelyn Lundeen. Dr. Abt, a founder of modern pediatrics, was notably referred to as a constant watchdog of infant care.[13] During those early years, children were cared for in adult accommodations and often shared a room with older sick patients. Dr. Abt designed and supervised the construction of one of the first hospitals for children, the Sarah Morris Hospital, which was part of the Michael Reese Medical Center. Upon completion in 1912, Sarah Morris Hospital had distinguished advanced features for its day which later became commonplace elsewhere. In 1922 at Sarah Morris Hospital, Dr. Julius Hess opened one of the first premature infant stations in the United States. This station, established through the charitable funding of the Infant's Aid Society, provided care for premature infants who were born at home, especially where home facilities were very poor. Many of the cases were charity cases and they came from every part of the city.[14]

At the Sarah Morris premature center, Dr. Hess designed the first human incubator. His electric-heated, water jacketed infant incubator and bed was credited with being the forerunner of the isolette in use today in premature nurseries.[15] Dr. Hess had become interested in the plight of these tiny newborns when he first saw them at the Columbia Exposition in 1896. Then they were sideshow curiosities displayed to the public in heated bed units by a Frenchman, Dr. Martin Couney, as a way of raising funds for their support. Ignoring Hippocrates' statement that no fetus coming into the world before the seventh month could be saved, Dr. Hess designed and built his own portable incubator which became known throughout the world as the Hess bed.[16,17] Over the years Dr. Hess and Nurse Lundeen became the nation's foremost authorities on the care of premature infants. The techniques they developed were later adapted to premature centers around the world. The work of these pioneers in the care of premature infants was chronicled by Freeman in 1965.[18]

Illinois was admitted to the Registration Area for deaths in 1918 and for births in 1922. The recording of birth and death statistics in the state conformed with standards laid down by the U. S. Bureau of the Census. 19

Analyses of general birth and death rates of a community over time, and contrasted with other communities or the country as a whole, serve as a barometer of the community's health. The impact of the united efforts of Chicago's Health Department and the numerous cooperating voluntary city groups was told statistically in the Department's annual report of 1929. The infant mortality rate was reported as 61 per 1,000 live births, the lowest in the history of the city. It was 63.8 in 1928 and 62.8 per 1,000 live births in 1927. The 1929 rate represented a decline of 38% in the city since 1915, as compared with a decline of only 26% in the U.S. Registration Area for Births.

The year 1929 showed 176 fewer deaths of children under one year of age than in 1928. A study of these deaths conducted by the Health Department showed that about one half of them occurred during the first two weeks of life. It was concluded that many of these could have been avoided with proper prenatal eduction and care. To help reduce this needless loss, lecture courses for expectant mothers were instituted at infant welfare stations by Commissioner Arnold Kegel in 1928.10

EVOLUTION OF MODERN PROGRAMS: 1932-1960

For a number of years prior to 1932, the activities carried out by the Office of the Commissioner of Health were done with limited legal authority, by reason of an adverse decision of the Supreme Court of Illinois.[20] Jennie Barmore had filed in that court at the June term, 1921, an application for a writ of habeas corpus which stated that she was unlawfully restrained of her liberty at her home in the City of Chicago by John Dill Robertson, Commissioner of Health, and Herman N. Bundesen, an epidemiologist of the Department of Health. The writ was awarded and respondents made due return, by which they admitted that they were restraining her from going about the City of Chicago and from following her usual occupation of boardinghouse-keeper for the reason that she was a carrier of typhoid bacilli; that they were restraining her by virtue of the authority given them by the statutes of the State and the ordinances of the City and the rules and regulations of the State Department of Health; and that her detention was necessary for the preservation of the health of the citizens of the City and the State. The facts stipulated by both parties were shown to be substantially true. However, attorney for the defense, Clarence Darrow, showed that according to state statute, the City of Chicago had no board of health but rather had established by ordinance an executive department of the municipal government known as the Department of Health which embraced the Commissioner of Health, the city physician and other assistants and employees. In the opinion of the court, the city council had no authority to delegate to a health officer the power and duties which the legislature said it might delegate to a board of health. The powers given to boards of health were extraordinary, and the legislature was evidently unwilling to leave to one person the determination of such important and drastic measures as were given to such boards. In the judgment and fidelity of a greater number acting together was the greatest security against the abuse of extraordinary power. This case set a precedent not only for Chicago but for all municipal health departments in the country.

In order to meet the danger inherent in this situation, a comprehensive ordinance passed by the City Council on May 4, 1932, created a new five member Board of Health which complied in all legal respects with the mandate of the court. This ordinance also established the legality of the Office of the Commissioner of Health and the work of the Department of Health.[2]

That year, newly elected Mayor Anton Cermak appointed Dr. Herman Bundesen as Health Commissioner. Dr. Bundesen previously served as Health Commissioner from 1922 to 1927, subsequent to the retiring Commissioner John Dill Robertson. He had a long standing record of service to the Health Department as well as to the public health profession.[21,22] His appointment as Commissioner effected a complete reorganization of the working personnel of the Department. A Division of Infant Welfare was established within the Bureau of Medical Services. Prenatal, infant and pre-school services were grouped under this division. Infant care continued to be the major activity.

In his 1932 report to the Mayor on the work of the Health Department, it was noted that attendance at prenatal and infant welfare clinics was larger than ever before and it was believed that this increase was a factor of importance in setting the new low mark of infant mortality. Tabulation was also given which showed the trend of increased hospitalization of obstetrical cases in the city as a whole and among those registered at prenatal conferences.10 Dr. Bundesen included in his report the following statement:

"Successful prenatal and natal care must be measured by the results obtained, that is, the reduction of maternal and neonatal death rates. Admittedly facilities of the Board of Health and all other maternity agencies for this type of care are too inadequate to expect significant results. However, there is a lack of standarization of methods and procedures among physicians, hospitals and maternity agencies. There should be an adequate cooperative maternity program worked out for the city as a whole and carried out according to unimpeachable standards. Only then can a maternal death rate reduction be expected. In the end, every expectant mother in the community must have the opportunity for adequate and correct prenatal confinement services."

Great movements in history arise from simple philosophical bases. In Chicago, during the 1930's, the great movement toward the prevention of neonatal death was led by the Health Department under the direction of Dr. Bundesen. The mission of the Health Department emanated from his belief that a life saved at this period is worth much, not only in mere years for the individual, but in the measure of his contribution to the life of his race.23

Professionals were enlisted to heed the sound advice of experts nationwide to make more effective use of knowledge and resources for those small premature infants, whose tragic and untimely deaths were in vain. This movement was generated in the wake of widespread national interest and supported by mortality statistics.

In Chicago, the movement grew out of recognition that the rich had access to the best care and that this same quality of care should be made available to the masses. To this end, committees were formed and commissions established composed of outstanding obstetric and pediatric specialists from Michael Reese Hospital, Northwestern Memorial Hospital, the University of Chicago and others. These professionals critically reviewed infant death records and autopsy reports, in order to determine the leading causes of neonatal deaths and to develop an aggressive plan of prevention.

Prevention through earlier and more adequate prenatal care became the focal message of the Health Department. There was an increase and expansion of health education endeavors, publications and news releases.

National and international attention was drawn to Chicago's progress in preventing premature infant deaths by way of the Exposition at the 1933 World's Fair-Century of Progress. Dr. Martin Couney's Infant Incubator Exhibit was installed and Chicago babies, prematurely born or underweight, received a chance for life by being enrolled in his infant incubator class. A total of 70 infants were cared for during the Exposition. Forty-one tiny tots, including four sets of twins and one survivor of a group of triplets, nursed to vigor at the Infant Incubator Exposition were guests, together with their mothers, at a colorful homecoming party given at the World's Fair. People prominent in the medical and nursing profession mingled with the infants. Among the notables who spoke over the WMAQ microphone on a nationwide N.B.C. radio broadcast were Dr. Herman Bundesen and Dr. Julius Hess.[24]

In 1934, Commissioner Bundesen introduced the Grade A Pasteurization Milk Ordinance, unanimously adopted by the City Council on January 4, 1935.2

The Board of Health adopted the U.S. Public Health Service Milk Code as regulation for the interpretation of the ordinance and Chicago's chief executive gave his whole hearted support to seeing to it that there was no interference with its enforcement. One of the health officer's main weapons in milk control was proper pasteurization. With the method of milk production demanded, together with pasteurization, Chicago's milk supply was raised to safe and wholesome standards. A 16% reduction in the infant mortality rate occurred in Chicago during the following year and it was believed that the improvement in the milk supply was at least a factor in this reduction.[25]

During 1934, a city-wide plan for the care of premature infants was inaugurated. The Chicago Department of Health and the premature stations at Sarah Morris and Cook County Hospitals combined their facilities for the care of these infants in Chicago and Cook County. Several basic principles governed their operation. First, it became mandatory that all premature births be reported to the Department of Health by telephone within one hour of delivery, followed by a written confirmation within 24

hours. As soon as the report of a premature birth was made, the Department of Health contacted the delivering physician, provided there was one in attendance, for permission to transport the infant to a premature station if such request had not been made at the time of reporting the birth. All transportation of these births, whether from a home to a hospital or from one hospital to another, was done by the Department of Health nurses who accompanied the ambulance. These nurses received special training in the handling of the infant during transport from Nurse Lundeen and the staff at Sarah Morris Hospital.

Second, the premature infant stations were supplied with incubators or some kind of heated bed as well as special equipment for oxygen and other emergency therapy. Medical and nursing personnel trained in premature care staffed the stations. Breast milk for the infants was obtained from wet nurses and visiting mothers at the Department of' Health's breast milk station which was opened in 1935. Women who gave milk were paid by the Department and this human breast milk was then distributed to needy individuals and also supplemented hospital supplies.

In addition, a field nursing service was developed for instruction of mothers in the care of infants, following their graduation from the station. A heated bed was loaned to graduate infants for use in the home. Outpatient clinics and other Department of Health stations maintained instruction courses for the mothers. Through grants of funds from the Children's Bureau, the centers were paid for hospitalization of infants who otherwise would have been denied this special care.

The spearheading of any such movement required the command of a strong personality. That personality was found in Commissioner Bundesen. During his tenure, milk which did not meet adequate standards of quality and purification was poured into the sewers of Chicago rather than be dispensed at Mother's Milk Stations. He erected in the public halls of the Health Department an electric light alerter system which flashed to identify every report of a premature death in the city's maternity hospitals. He enlisted the foremost premature nurse specialists in the program of public health education for Health Department nurses. Known and respected by the citizenry at large, Dr. Bundesen became President of the Board of Health and with full statutory authority, continued to direct the maternal and infant health programs of the city. In his writings he claimed failures as well as success and prefaced his publication with a critical self-appraisal of his own endeavors as a public health official. 23,26,27

"Chicago Retains Record for Low Baby Death Rate: Sets a New Standard for Big Cities," read the column headlines of the Chicago Tribune, January 5, 1937. Chicago in 1936 again sustained its reputation as the healthiest large city for newborn babies. The infant mortality rate for 1936 was 35.4 per 1,000 live births, the lowest rate ever attained in Chicago or any other large city that year. 10 The reduction, health officials said, placed Chicago in the position of leading the world in decreasing infant mortality rates.[28] During 1939, 105 conferences for infants were held each week in the 34 infant welfare stations throughout the city. The registration of new cases at the conferences showed little variation as did the birth rate year by year from 1926 to 1939. A total of 36,171 patients were cared for in 1939, and these cases made a total of 175,015 visits since the program's inception. Infant mortality and maternal mortality rates continued to decline.[7]

Between 1935 and 1939 there was increased interest in the advantages offered by premature transportation. Over these four years the number of premature infants transported tripled from 532 to 1,919. The incubator ambulances maintained by the Department of Health were located at the Chicago Maternity Center which provided obstetrical services to women in their homes and performed home deliveries. This charitably funded center was involved in the home delivery of approximately 2000 infants annually or 3% of the total annual births in the city.

A special hospital inspection unit was assigned by the commissioner, composed of Health Department physicians and nurses, to assist hospitals in carrying out the "Regulations for the Conduct of Maternity Hospitals, Maternity Divisions of General Hospitals and Nurseries for the Newborn." The results were cited as a gratifying improvement, both in the techniques and physical aspects of the maternity services, in practically all hospitals.[29]

The infant mortality rate continued to decline, the rate for 1940 being 28.8 per 1,000 live births. The percent of deliveries in hospitals also continued to increase along with maternity hospital inspection services.[10]

Neonatal and maternal death investigations were conducted by staff obstetricians. The protocol of every post-mortem examination performed in these cases of death was forwarded to the central office where it was studied by a sub-committee of Cook County for the object of learning more about the relative factors, causes and possible prevention of these deaths.

Reckie and Miller cited in 1949 that there was clear evidence of excellence in Chicago's antenatal, natal and postnatal services as shown in the average general decline in mortality rates. The program for the care of premature infants developed by the Chicago Health Department during the previous ten years, along with the excellent educational programs carried out in clinics and at Mothers' Milk Stations by Health Department nurses, were outstanding achievements.[30]

During the latter part of 1952, the Health Department published and distributed throughout the United States, Commissioner Bundesen's 272 page book titled "Progress in the Prevention of Needless Neonatal Deaths." This publication, supported in part by a grant from the American Committee on Maternal Welfare, was the result of the intensive investigations into the causes of neonatal mortality in Chicago during the years 1936 to 1949. Its publication involved one of the most extensive analyses ever undertaken by a city health department. Chicago had taken the lead in helping to solve problems connected with neonatal deaths and, from the information obtained, utilized all available public health methods for achieving a reduction in the city's neonatal deaths.

The tenure of Dr. Herman Bundesen as Commissioner of the Department and President of the Board of Health was not without criticism. Objections were raised chiefly on grounds of organization and management. In 1958, Karlem described the organizational chart of the health department, commenting that it failed to portray the importance of the President of the Board. While Dr. Bundesen had established an enviable record in the public health field for the activities of his department, he had created a one-man management system. The City Council Appropriation Bill provided for a Commissioner of Health and a President of the Board of Health but, in fact, these positions were filled by one man.[31]

Dr. Herman Bundesen never retired from the Board of Health. He died in 1960 having served for 34 years as the city's chief health officer. His legacy to the city remains intact in maternity hospital regulations, his voluminous studies of infant and maternal morbidity and mortality and his gift to the people, the classic, "Dr. Bundesen's Baby Book," a loving guide to well child care from a loving parent and physician.

DEVELOPMENT OF MODERN PROGRAMS: 1960-1980

Following Dr. Bundesen, Dr. Samuel Andelman was appointed Health Commissioner of Chicago. Dr. Andelman, formerly the Assistant Commissioner, was well prepared to carry on the mission and worthy record of his predecessor. Now Commissioner of Health of the Village of Skokie, Dr. Andelman vividly recalled his previous years of tenure, 1960 to 1968. "When Chicago corporate funds proved insufficient to meet the growing needs o£ our maternal-infant population, federal funding was sought." The Chicago Maternal Infant Care Project Grant 502 was the second awarded in the nation following that to Baltimore, Maryland. When the Children and Youth Projects were made available through the Children's Bureau, the first project, 601, was awarded to Chicago. Incumbent Mayor Richard J. Daley invested the same confidence and support in the new Commissioner of Health as had previous mayors in Dr. Bundesen.[26]

As part of the national effort in the field of mental retardation, Maternity and Infant Care Projects (M. and I.) were funded as a result of the 1963 Amendments to Title V of the Social Security Act. The M. and I. programs were intended to demonstrate a variety of approaches toward prevention of mental retardation and reduction of infant mortality.[32]

National and international epidemiologic studies of infant and maternal mortality and morbidity during the decade carried to prominence the concept of the high risk pregnancy. Studies, such as those conducted by Lilienfeld and Parkhurst, demonstrating the continuum of reproductive loss associated with maternal risk factors, marked an important beginning for research in perinatology.[33]

Project 502 enabled expansion of the city's services to the pregnant woman and high risk infant who could not afford private medical care. It was designed to provide interdisciplinary health care to women during pregnancy, labor, delivery, and postpartum period, as well as to provide family planning and infant care services. These services included medical and dental care, social and nutrition service, patient education, nursing services, transportation and child care. Care as well as detection of physical, emotional and psychological abnormalities was provided to residents in lower socio-economic areas of Chicago who, as a general rule, did not have access to board eligible or board certified obstetricians and pediatricians in their own communities.[10]

Zackler, Andelman and Bauer reported the impact of project 502, comparing the pregnancy outcome of project adolescents age 15 years and under with those of non-project adolescents. While this study was criticized for some of the conclusions related to the risk status of the adolescent, even critics admitted pleasure in reading that specialized services really had done some good. The authors had demonstrated that the hazards to girls less than 15 years of age can be reduced by giving them the care which the high risk patient received.[34]

During the 1960's, new techniques were devised for monitoring maternity patients, screening for high risk patients and providing for care of the fetus and the newborn. Special newborn intensive care units and perinatal centers were established. In June, 1971, the House of Delegates of the American Medical Association issued a statement subsequently endorsed by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists which, in summary, extolled the advance of intensive care management of high risk patients and urged the development of regionalization programs which would make such management available on a state and nation-wide basis .35

The decade of the 70's witnessed renewed and intensified interest and support for perinatal care at national, state and local levels.[35,36] In Illinois, the General Assembly signed into law Public Act 78-557 which provided for the development of a statewide plan of perinatal health by the Illinois Department of Health. In compliance with this act, the Illinois Department of Public Health (I.D.P.H.), in conjunction with the Comprehensive State Health Planning Agency and with the assistance of a designated advisory committee, the Illinois Committee for Perinatal Health, completed the State Plan for Perinatal Health in July, 1974.[37]

The major components of the Illinois Plan included the establishment and circulation of guidelines for minimum hospital criteria for perinatal care on three levels: general, intermediate and intensive care. Institutions were surveyed, reviewed and assigned levels of care designations according to these criteria. Five perinatal regions of service were mapped out by counties of comparable population base, natality data and number of available family, obstetric and pediatric practitioners. Perinatal centers were located in each region. Guidelines for the transport of high risk infants and mothers to regional perinatal intensive care centers and institutions were developed collaboratively with the Emergency Medical Service and Highway Safety Departments of the State. A public information coordinator position was established and the idea of a state-wide perinatal newsletter was conceived. A perinatal education coordinator role was established in each perinatal center. A list of criteria to be used for the identification of the high risk mother was developed. A codebook and code-sheets for the uniform collection of baseline and yearly data on perinatal mortality and morbidity were issued. While these common elements formed the core of the plan, the overriding philosophy dictated discretionary regional implementation.

In 1976, national guidelines were developed with regard to perinatal regionalization and, by 1977, more than 13 states and several multiple state groups had established regional perinatal plans.[38] Paralleling the regionalization movement, federal funds were authorized under Title V as block grants to states which were shown to contribute excessively to the national infant mortality rate. Illinois, cited as third among these top priority states was a recipient of these "Improve Pregnancy Outcome" (I.P.O.) grants. In order to be eligible to receive funds under this authorization, the state agency had to have an approved plan for perinatal care. Illinois' regionalization plan assured eligibility and, as stated by Dr. Patricia Hunt, Chief of the Division of Family Health, I. D. P. H. , the five year project funds were to be used not to pay for activities already in progress or established state responsibilities, but to help the state develop new information and methods of gathering data to identify high risk factors.[39]

In accordance with federal and state guidelines, an I.P.O. narrative and grant application was submitted to I. D. P. H. in 1976 by Dr. Donald Dye, Directory of Maternity and Infant Care Programs of the Chicago Department of Health. Dr. Dye had been appointed program director of project grants in 1975 under Commissioner Murray Brown who had served from 1969 to 1979.

The Department of Health's I.P.O. grant application combined a number of new ideas with traditional health programming concepts aimed at reducing infant mortality by three percent annually in selected high risk population areas of the city. The initial two target areas chosen were the maternal service areas of station 9 and station 30. Both stations were located in Chicago Housing Authority Developments where the residents were subject to the multiple problems associated with lower socioeconomic, inner city communities. Reported infant mortality for those areas were 27.2 and 34.9 per 1,000 live births respectively. The objectives of the I.P.O. project called for the analysis of available data to improve the identification of high risk pregnant women and infants; the collection and analysis of specific data concerning pregnancy outcome; the establishment of a referral and followup system to insure that appropriate level of care was provided to pregnant women and their infants; the coordination of consumers and providers in the area to determine their own needs and desired services; and finally, initiation of specialized patient education.[40]

Having been granted the necessary funds, the first activity carried out was a contracted study of multivariable risk factors related to infant mortality for Chicago and compared with the nation as a whole and 55 other large cities of the United States .41 Results of this study showed that Chicago's 1965 to 1975 infant death rates in general were declining but not as fast as those of the comparison groups. It was concluded that the number of black births was the most important variable in explaining variation in mortality levels. Yet, compared to ten other cities which had higher percentages of black births, Chicago's neonatal death rate for blacks was the third highest. One reason given for the high neonatal mortality rate was the unusually high proportion of very low birth weight infants. These infants accounted for one-half of the neonatal deaths. Given the prevalence of low birth weight infants, it was suggested that the needs of pregnant women were not being met with appropriate perinatal services-before, during or after delivery.

Recognizing the need to evaluate and refine currently employed high risk criteria for more effective patient care management, the Problem Oriented Perinatal Risk Assessment Record System (POPRAS), developed by Dr. Calvin J. Hobel and associates in 1973, was incorporated into the patient record system at the two project stations in 1978.42

PRESENT PROGRAM GOALS: 1981

Testa and Wulczyn (1980) described selected facts and trends about the children of Illinois and showed how today's indicators compare to similar measures taken over the past 20 years.[43] They reported that in Illinois, the risk of a child dying before reaching his first birthday was among the highest in the nation. The State's infant mortality rate of 15.9 deaths per 1,000 live births in 1977 ranked sixth highest in the country. During the past 15 years, Illinois experienced consistently higher infant mortality rates than the overall national rates. Prior to the 1950's, however, Illinois rates were lower than the infant death rates of most other states. In the early 1960's a series of measles epidemics in Illinois helped to push the State's rates above the national level, where they have remained up to the present .44

The risk of death for non-white infants consistently had been twice the risk for white infants; a pattern that has not changed appreciably since the 1960's.[45]

One explanation given as to why infant mortality rates continued to exceed national levels was that poor access to proper medical care, both during pregnancy and after birth, accounted for some of the increased risk of infant death in the City of Chicago. In 1977, the City's infant mortality rate was 21.4 deaths per 1,000 live births. The rate for white children in Chicago was 14.6 deaths and for black children and children of other races, the rate was 27.7 deaths per 1,000.

The death rate among newborns less than 28 days old was cited as an important indicator of the effects of medical and health factors on infant mortality. Neonatal mortality in Chicago attained a rate of 14.6 deaths per 1,000 live births in 1977, accounting for nearly two-thirds of all infant deaths. The rate for non-white newborns was 19.0 deaths, compared to 9.8 for white newborns.

Although medical and health factors exert important effects on the risk of infant death, their impact on life chances in a particular community are largely secondary to the overall standard of living prevalent in the community. Kessner, in 1973, provided evidence that poverty, poor education and improper health habits constitute a set of social risk factors, which increase the chances of inadequate prenatal and postnatal care and early childhood deaths, independent of the quality of available medical care .43 These same social risk factors were documented by Robertson in 1918.[8] The consequences of these social risk factors are summarized today by the fact that nearly three-quarters of all low-weight births are non-white and one-half of all neonatal deaths are low-birth-weight infants.

Comparing changes in the infant death rates for rural and urban areas over the years, these changes have been attributed in part to changes in the makeup of the population groups which lived in these areas.[44] The 1950's were a time of large population movements: inter-state migration from the southern part of the country to large northern cities. This migration to the cities was in large part a movement of non-white families. In addition to reflecting the migratory trends of certain racial and ethnic groups, the movement also was noted to reflect the residence changes of high health risk populations, as indicated by the decline in infant mortality rates in rural areas and the rise in urban areas.

The Chicago Department of Health in its continuing efforts to provide maternal and infant services to the largely high risk pregnant population of the City is limited by funding, medical and nursing staff as well as facilities.

Although many sources of funds support the program, there has been no increase in these funds overall since 1974. As a result, the program has not been able to keep pace with inflation nor accommodate the increased number of patients to be served. Physician staff is largely part-time and a diminished public health nursing staff has required restriction of city-wide home visiting services. Only areas specifically designated as serving high risk populations continue to receive public health nursing home visits. During the past year, three stations which provided prenatal care were closed because of physical deterioration.

Despite limitations, the current mission statement of the Health Department contains two specific goals of the present Commissioner, Dr. Hugo Muriel. The first is to reduce Chicago's infant mortality rate by 20% by 1983. Community areas with high mortality rates will receive intensified service. The second goal is to bring all Chicago maternity hospitals up to the standards of Level II and III criteria, so that specialized care will be available to all mothers.

These goals are the same as the goals of the Chicago Health System Agency and an Assistant to the Commissioner has been appointed to work toward their accomplishment.

The social machinery has been established, a productive history has been recorded and through the efforts of private, voluntary and official agency staff, progress in the prevention of needless perinatal loss in Chicago continues.

REFERENCES

l. Burke E.: Speech on American Taxation, 1774. The Treasury of Irish Eloquence. New York: Murphy and McCarthy, 1885.

2. Proceedings of the City Council of the City of Chicago. Chicago: J. S. Thompson and Co., 1878, 1932, 1935.

3. Illinois Revised Statutes, 1979; State Bar Association Edition. St. Paul, Minn.: West Publishing Co. Chapter 24, Div. 17.

4. Andreas A. T.: History of Chicago From the Earliest Period to Present Time, Vol. 1. Chicago: A. T. Andreas, 1884.

5. Annual Appropriation Ordinance. City of Chicago 1876, 1902, 1914, 1932, 1935, 1980.

6. DeLee J.: A Brief History of the Chicago Lying-In Hospital. Alumni Association Chicago Lying-In Hospital and Dispensary. Souvenir, 1895-1931, 1931.

7. Speert H.: Obstetrics and Gynecology in America: a History. Baltimore: Waverly Press, Inc., 1980.

8. Robertson J. D.: The Chicago Health Department Report to the Mayor, 19111918. Chicago, 1919.

9. Plummer M.: The milk commission of Chicago and its work. Charities and the Commons, II, 1903, pp. 207-211.

10. Chicago Department of Health Annual Reports, 1911-1918; 1929; 1932; 1933; 1936;1940;1950;1963-1971.

11. Winslow C. E. A.: William Evans and the health department of Chicago. World Today, 19:730-734, 1910.

12. Pancoast C. L.: Chicago Health Department exhibit. American City 6: 750751, 1912.

13. Kunstadter R.: Goodbye to Sarah Morris. Chicago Medicine. Feb. 3, 1968.

14. Lundeen E.: History of the Hortense Schoen Joseph Premature Station. Michael Reese Hospital Archives, 1938.

15. Hess J.: An electric heated water jacketed infant incubator and bed. J. Am. Med. Assoc. 64:1068-69, 1916.

16. McAllig P.: Memorandum: The Hess Incubator. Prepared for the Office of Development, Michael Reese Hospital, Michael Reese Hospital Archives, 1974.

17. Hess J.: Chicago plan for care of premature infants. J.A.M.A. 146:891-893, 1951.

18. Freeman L.: Hospital in Action. New York: Rand McNally, 1956, Chapter 5.

19. Vital statistics for Illinois. Am. J. Public Health. 21:1261-1262, 1931.

20. The people vs. Robertson, 302, Ill. In West's Illinois Digest. St. Paul, Minn., 1922, pp. 422-436.

21. Statement regarding the dismissal of the health commissioner. Science. 67:153, 1928.

22. The dismissal of Dr. Herman N. Bundesen. Am. J. Public Health. 18:69-70, 1928.

23. Bundesen N.: Progress in the Prevention of Needless Neonatal Death: Report of the Chicago Health Department, 1951.

24. Infant reunion. A Century of Progress. Publicity Division, Chicago, July 25, 1933.

25. Bundesen N.: Inauguration Grade A pasteurized milk in the City of Chicago. Am. J. Public Health. 27:680-684, 1937.

26. Andleman S. A.: Personal communication, Oct. 22, 1980.

27. Rozenberger G.: Personal communications, Nov. 25, 1980.

28. DeKruif P.: Chicago keeps babies alive. Ladies Home Journal. 55:18-19, 1938.

29. Sharpshooting; Chicago save lives of premature babies. Survey. 71:340, 1935.

30. U.S. Public Health Service. The Chicago Cook County Health Survey. New York: Columbia University Press, 1949.

31. Karlem H.: The Governments of Chicago. Chicago: Courrier Publishing Company, 1948.

32. Wallace H.: Status of infant and perinatal morbidity and mortality. Public Health Reports, 1978, p. 93.

33. Lilienfeld A. M., Parkhurst E.: A study of the association of factors of pregnancy and parturition with the development of cerebral palsy. A preliminary report. Am. J. Hygiene. 53:262, 1951.

34. Zackler J., Andleman S., Bauer F.: The young adolescent as an obstetric risk. American Journal of Obstetrics and Gynecology. 103:305-312, 1969.

35. American Medical Association. House of Delegates Report. Atlantic City, 1971.

36. U.S. Department of Health, Education and Welfare: Project for Intensive Infant Care. DREW Publication No. (H.S.A.) 74-5010. U.S. Government Printing Office, Washington, D. C. , 1974.

37. A Plan for Perinatal Health in Illinois, Illinois Department of Public Health (I. D. P. H.), 1974.

38. Committee on Perinatal Health. Toward Improving the Outcome of Pregnancy. White Plains, NY: The National Foundation, 1976.

39. Minutes of Illinois Perinatal Advisory Committee, (I.P.A.C.), Feb. 11, 1976.

40. Chicago Department of Health: Maternity and Infant Care Project to Improve Pregnancy Outcomes, 1976.

41. Pratt M. W., Janus Z. L.: Is Chicago Different from Other Major U.S. Cities? Washington, D. C.: Information Science Research Institute, 1977.

42. Hobel J., Hyvarinen M. A., Okada D., et al.: Prenatal and intrapartum high risk screening: 1 prediction of the high risk neonate. Am. J. Obstet. and Gynecol. 1973, 117.

43. Testa M., Wulczn, F.: The State of the Child. Chicago: The University of Chicago, 1980.

44. U.S. Department of Health, Education and Welfare, Public Health Service, National Center for Health Statistics, Vital Statistics for the United States. Washington, D. C.: U.S. Government Printing Office, 1950-1976.

45. Kessner D., et al.: Infant Death: An Analysis by Maternal Risk and Health Care. Institute of Medicine, National Academy of Sciences Washington, D.C., 1973.


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